RN - Utilization Review

The Utilization Review (UR) Nurse has a strong clinical background blended with well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. Utilizes appropriate criteria and interprets the implications of clinical status and the medical treatment plan with current federal regulations/guidelines thereby expediting the billing process, payment and preventing governmental sanction. The UR nurse is responsible for performing comprehensive admission, concurrent and retrospective UR related reviews and functions to ensure that appropriate data is tracked, evaluated and reported. This individual actively participates in process improvement initiatives, working with multiple departments and multi‑disciplinary staff. This role requires current and accurate knowledge regarding commercial and government payers as well as accreditation regulations/guidelines/criteria related to UM. Required Qualifications Upon hire: Washington Registered Nurse License. 3 years of Nursing experience. Preferred Qualifications Bachelor's Degree in Nursing Associate's Degree in Nursing 3 years of experience in Utilization Review, Care Management, Quality Management, and/or Discharge planning. Benefits Our best‑in‑class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities. E‑EO Statement Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. #J-18808-Ljbffr